Canine Rehabilitation Pain Inventory
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client Name
*
First Name
Last Name
Pet Name
*
Description of Pain
Please rate your dog's pain
What best describes your dog's pain at its WORST in the last 7 days?
*
No Pain
0
1
2
3
4
5
6
7
8
9
Extreme Pain
10
0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain at its LEAST in the last 7 days?
*
No Pain
0
1
2
3
4
5
6
7
8
9
Extreme Pain
10
0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain on AVERAGE in the last 7 days?
*
No Pain
0
1
2
3
4
5
6
7
8
9
Extreme Pain
10
0 is No Pain, 10 is Extreme Pain
What best describes your dog's pain right now?
*
No Pain
0
1
2
3
4
5
6
7
8
9
Extreme Pain
10
0 is No Pain, 10 is Extreme Pain
Description of Function
How has pain interfered with your dog's general activity in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's enjoyment of life in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to rise to standing from lying down in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to walk in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to run in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
How has pain interfered with your dog's ability to climb stairs, curbs, doorsteps, etc in the last 7 days?
*
Does Not Interfere
0
1
2
3
4
5
6
7
8
9
Completely Interferes
10
0 is Does Not Interfere, 10 is Completely Interferes
Overall Impression
What best describes your dog's overall quality of life over the last 7 days?
*
Please Select
Poor
Fair
Good
Very Good
Excellent
Submit
Should be Empty: